You can download and print our Medical Record Release form or obtain a form from the front desk at any Mid Atlantic Retina location.
Your records will be sent to you upon receipt of the signed Medical Record Release form.
You can request records from Mid Atlantic Retina three ways:
- Mail the completed form to your Mid Atlantic Retina office.
- Fax the completed form to your Mid Atlantic Retina office.
- Bring in the completed form to your Mid Atlantic Retina office.
You will receive a call from our office indicating the cost to copy your records. Mid Atlantic Retina charges only the state regulated charge for copies of your medical record.
Please allow up to 30 days to process your request.
Authorization Signature for Your Records Release
By law, the following authorized people are able to sign for the release of your health information:
- Yourself (not your spouse)
- A parent (for patients younger than 18 years of age)
- Legal guardian (guardianship documentation is required)
- Power of attorney if patient is unable to sign (legal documentation is required)
- Estate representative for a deceased patient (estate documentation is required)